Laserfiche WebLink
02/23/2001 10:05 2094683433 FIFTH FLOOR p R I GIN A L <br />WELL PERMIT APPLICATION FORM <br />SITE <br />MITIGATION <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES UNIT IV <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA-, 95202 <br />(209) 468-3449 G. (• <br />NON.REFUNDABLE PE MIT EXPIRES 1 YEAR FROM DATE ISSUED <br />application is hereby made to San Joaquin County for a permit to construct and/install the work described. This application is made In compliance with San <br />Joaquin County Development Title. Chapter �1 115.3 and the Standards of San Joaquin Assessor's County Public Health Services, Environmental Health Division. <br />�/ / ry � Zip,1S2�:,�Parcel# <br />7�6 t Cross Street -v n1 i <br />,NELLLoeaton Y , � � .o _. hone# <br />PROPERTY <br />C-57 <br />tiltln Lic# 2Z0 -Phone# ti'z <br />% <br />Consultant I Sub Contractor r✓ �, "� <br />, Township <br />Range Section <br />GIS Coordinates: X Y <br />WORK TO BE PERFORMED: 0 DESTRUCTION (cOVER-BORE GROUT type below) <br />[] <br />0 NEW WELL ! BORING (CPT, GEOPROBE. HYDRO?UNCH, HAN •AUGER, OTHER') 0PRESSURE GROUT <br />'SOIL BORING a <br />WELL 1F Grout Specifications: <br />'Other: <br />COMMENTS: <br />TYPE OF WELL <br />INSTALL-ATION TYPE <br />Q MONITORING <br />0 HOLLOW STEM <br />0 EXTRACTION <br />1] AIR HAMMERIORIVEN <br />0 VAPOR <br />MUD ROTARY <br />0 AIR SPARGE <br />rPUSH POINT <br />i SOIL BORING <br />❑ HAND AUGER <br />0 OTHER:_,[] <br />OTHER`— <br />CONSTRUCTION SP IFICATIONS W ELL CASING DIA: <br />DIA. OF BOREHOLE MULTIPLE CASINGS. 13 YES O <br />PE OF CASING: 0 STEEL 0 PVC a OTHER: <br />CASING THICKNESS--- <br />TREMIE TYPE TO BE USED: p AUGERS I HOSE <br />DEPTH OF GROUT SEAL—S—W­ <br />OTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />GROUT SEAL PUMPED: I Yes ONO (N <br />GROUT SpECIFICATIONS: <br />APPROX. BORING DEPTH 0 BOLTED TRAFFIC BOX or STOVE PIPE <br />CONDUCTOR CASING PROPOSED? (if YES, list specifications here): <br />'COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS ON E FOR AL ENCROACHMENT <br />REQU RED INS ECTIIONS. <br />CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE <br />d this application and that the work will be done in accordance with San Joaquin <br />I herebYcertify tha have prepare <br />County Ordinancts, es an_ -Regulations, and all applicable California State Laws. <br />71tle1Company„2 <br />Signed X/ / <br />Print Name /I- /` nFPARTMENT USE ON <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: <br />Application Accepted E <br />Grout Inspection By_ <br />Destruction Inspection <br />COMMENTS/CONDI <br />Date <br />I .f <br />Issued <br />Inspection By <br />Date___ 1 <br />ACCOUNTING ONLY: AID# <br />PE CODES FEE INFO AMOUNT REMITTED CHECj#]L <br />DATE PEJ <br />C-57 WCC WAIVER_ C-57 Letter of Authorization to sign permit <br />Z <br /># INVOICE <br />Ichment doc— 9/27/00 <br />FEB 23 '01 10:00 2094603433 PAGE.002 <br />4Z <br />